Indian Pediatrics - Editorial

Letters to the Editor

Indian Pediatrics 2003; 40:800-801

Laparoscopic Removal of Twisted Ovarian Cyst in a 22 Hour Old Neonate

A female child weighing 2.7 kg was born at full term. There was no history of any maternal illness. An antenatal ultrasound scan done at 36 weeks showed a cystic lesion in the abdomen. Previous ultrasound done at 16 weeks was normal. The child was crying excessively and refused to feed. On examination, an ill-defined slightly tender mass was palpable in the umbilical and right lumbar regions. There were no other associated anomalies. An ultrasound of the abdomen showed a 5×6 cm cystic lesion to the right of the umbilicus with septae and no internal echoes or calcification. Keeping the possibility of a mesenteric cyst, an ovarian cyst or a duplication cyst with complications in mind, a laparoscopy was performed. Laparoscopy revealed a huge ovarian cyst, about 6 cm × 7 cm arising from the left ovary, lying in the right lumbar region below the liver. The cyst was twisted over its pedicle causing congestion of the left adenexa. The right adenexa was normal. After untwisting the cyst, it was decompressed with a wide bore (18 gauge) laparoscopic needle. The cyst was then completely dissected from the viable left adenexa and extracted. The total operating time was 35 minutes. The child had an uneventful recovery and started feeding 6 hours later. He could be discharged 40 hours later. The histological examination revealed a follicular cyst of the ovary and fluid showed no malignant cells.

Improvement in imaging techniques and a trend towards routine antenatal ultrasound scanning has increased the frequency of intrauterine diagnosis of many congenital defects and malformations. A cystic mass in the female fetus could be an intestinal duplication, hydronephrosis, meconium cyst, mesenteric, urachal, omental, choledochal or ovarian cyst, or only a bladder distension. Lymphangiomas, mesenteric cysts and omental cysts may be the most difficult to distinguish from an ovarian cyst, and early surgery is indicated if the diagnosis is not clear and neonate shows some signs of complica-tions. Laparoscopy can be used to extend our diagnostic capabilities, and its application continues to evolve with increasing experience among pediatric surgeons, and availability of smaller sized instruments. On laparoscopy, this child was found to have a huge ovarian cyst with nearly 270-degree torsion and a congested adenexa. Larger cysts carry a greater risk of torsion with subsequent loss of the ovary, and hence a surgical intervention is indicated. In the present case, the left gonad was not macroscopically visible. However, we restricted the surgery to complete removal of the cyst as reports show presence of ovarian tissue even if no ovary is macroscopically visible(1). Laparoscopy avoids the disadvantages of large scars, adhesion formation, even gonadal loss in cases of instant surgery(2) and also danger of life-threatening complications when the approach is too conservative(3), Laparoscopy is well tolerated not only by infants, but also by neonates. It demands small insufflations pressure (not above 8 mm Hg), with instant adjustments made according to the situation encountered. To the best knowledge of the authors, this neonate operated at 22 hours of life is the youngest on whom a complete intraperitoneal ovarian cystectomy has been done laparoscopically.

Amar Shah,
Anirudh Shah,
From the Department of Pediaric Surgery,
N.H.L. Municipal Medical College,
K.M. School of Postgraduate Medicine &
Research, V.S. Hospital,
Ahmedabad,
India.
E-mail: [email protected]

References

1. Brandt ML, Luks FI, Filiatrault D, Garel L, Desjardins JG, Youssef S. Surgical indications in antenatally diagnosed ovarian, cysts. J Pediatr Surg 1991; 26: 276-282.

2. Bagolan P, Rivosecchi M, Giorlandino C, Bilancioni E, Nahom A, Zaccara A et al. Prenatal diagnosis and clinical outcome of ovarian cyst. J Pediatr Surg 1992; 27: 879- 881.

3. Hengsten P, Menardi G. Ovarian cysts in the newborn. Pediatr Surg Int 1992: 7: 572-575.